Quantifying Value in an Iterative Disease-Site Specific Peer Review System

From the 2023 HVPA National Conference

Leslie Chang MD (Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine), Jean Wright MD

Peer review is a multidisciplinary meeting in radiation oncology that is an important aspect of quality assurance by reviewing case-specific qualitative decisions in treatment planning.  Noncompliance with cooperative group protocols negatively impacts clinical outcomes and peer review provides an opportunity for plan improvement. However, there is little guidance for specific peer review processes and it is important to identify key metrics that contribute to quality improvement.

To implement a pilot project assessing the greatest impact of peer review on treatment planning by developing an iterative peer review quality assurance workflow and utilizing a dynamic peer review checklist tool to track plan review and modification in two disease-site specific peer review groups.

We implemented an iterative peer review checklist tool and online treatment planning registry to document recommendations and time spent in breast and thoracic disease-site specific peer review groups. Plan review included discussion of the clinical scenario, radiation dose/fractionation, prescription, organs at risk and target volumes, planning metrics including dose volume histogram and patient setup. Pre-treatment review of volumes and plans occurred prior to treatment start for definitive plans of less than five fractions or using protons, and cases were re-reviewed in subsequent sessions to complete checklist items as needed. Reviews were graded as follows: discussion of alternative approach (no required changes), minor recommendations (changes recommended at attending discretion) and major recommendations (changes required). Students t-test and chi-squared analysis were used to identify statistical significance.

We identified 723 peer reviews over a 3-month period: 275 thoracic reviews of 195 unique patients (32% reviewed more than once), and 448 breast reviews of 273 unique patients (48% reviewed more than once, most commonly for a boost plan), data shown in Table 1. Pre-treatment review was completed on time in 91.6% of thoracic patients and in 72.2% of breast patients. On average, pre-treatment review doubled the amount of time spent per case, (4:47min versus 2:03min, p<0.01) and resulted in significantly more discussion (29.3% vs 9.3%, p<0.01), minor changes recommended (13.2% versus 4.8%, p<0.01) and plan revision (19.2% versus 2.4%, p<0.01). Thoracic pre-treatment reviews were twice as long as breast (5:43min versus 3:00min, p<0.01) and had a greater proportion of cases prompting discussion (26.7% vs 13.2%, p<0.01) and minor changes recommended (12.8% vs 6.3%, p<0.01). The most frequent discussion/recommendation topics also varied by group with planning metrics in thoracic cases (14.9%) and setup imaging including PORT films and electron setup (5.1%) in breast.

Iterative plan review with pre-review for selected cases encouraged educational discussion and plan revision, with notable variability by disease site. Thoracic cases required longer review time and had more frequent plan change recommendations likely reflecting differences in case complexity. In contrast, setup imaging in breast cases, which are more commonly 3D or electron-based, more frequently warranted discussion/revision and should be considered within the peer review paradigm. 

Clinical Implication:
This initiative identified the volume and duration of peer review cases including required repeat review for adaptive or boost planning. We have adjusted our clinical workflow by increasing the frequency of disease site specific peer review to 2 hours weekly for thoracic and 1.5 hours weekly for breast to improve timing of peer review. In addition, this study provides evidence for the importance of multi-provider review setup imaging in 3D planning.

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